Clinical Documentation Improvement Nurse Supervisor Job at San Bernardino County – Arrowhead Regional Medical Center, Colton, CA

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  • San Bernardino County – Arrowhead Regional Medical Center
  • Colton, CA

Job Description

Arrowhead Regional Medical Center (ARMC) is looking for a Clinical Documentation Improvement Supervisor to supervise professional staff engaged in CDI programs and activities to ensure coded diagnosis accurately reflect the patient’s clinical status and care. This position will be engaged with supervising staff  in the analysis of health record documentation to ensure the complexity of care is adequately and accurately documented in the patient's medical record in support of quality patient care and a healthy revenue cycle. Positions report to Clinical Director Care Management.

Overview: Clinical documentation improvement (CDI) is the process of reviewing medical record documentation for completeness, specifics, and accuracy, reviewing disease process, diagnostic findings, and what the documentation might be missing. A Clinical Documentation Improvement Nurse manages, assesses, and reviews a patient’s medical records to ensure that all the information documented reflects the patient’s severity of illness, clinical treatment, and the accuracy of documentation. Part of the role is to perform concurrent reviews of medical records, validate diagnosis codes, identify missing diagnosis, and query physicians and other healthcare providers for more specifics so documentation accurately reflects the patient’s severity of illness. In addition, CDI nurses educate physicians on the importance of supplying the proper information needed for correct documentation.

Qualifications

Availability: Must be available to work Day Shifts, Weekends, and Holidays. Applicants must indicate availability on the supplemental questionnaire. 

-AND-

Candidates must possess ALL of the following:

License: Must possess and maintain Registered Nurse licensure with the State of California Board of Registered Nursing.

Experience: Three (3) years of experience as a Registered Nurse in an acute care hospital, which included one (1) year of case management experience and one (1) year of experience as a lead or charge nurse. Experience may be concurrent.

Certification: Must possess and maintain current Healthcare Provider level Basic Life Support (BLS) certification.

Job Tags

Holiday work, Full time, Shift work, Weekend work, Day shift,

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